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PubMed1999

Continuous-processing related ERPS in adult schizophrenia: continuity with childhood onset schizophrenia.

BACKGROUND: Previous work with schizophrenic children disclosed deficits on two continuous performance tests (CPTs) and ERP indices of reduced attentional resource allocation. METHODS: The two CPTs were administered to adult schizophrenics and matched control subjects. The simple CPT required only that the subject respond whenever the target digit was displayed. The complex version required a response whenever any digit was displayed on two successive trials. Event-related potentials (ERPs) were recorded during task performance. RESULTS: Schizophrenics had fewer hits on both CPT versions, showed a greater drop in performance from the simple to the complex CPT, and took longer to respond than controls. The processing negativity (Np) showed a greater amplitude increase from nontarget to target in normals than in schizophrenics, and the overlapping P2 component was more negative in normals. P3 latency was longer in schizophrenics, but P3 amplitude did not differ. CONCLUSIONS: Group performance and processing negativity effects replicated those from an earlier study of schizophrenic and normal children administered the same versions of the CPT, suggesting similar abnormalities in the allocation and modulation of information processing resources.

Adult↗
PubMed1982

Application of cost-benefit and cost-effectiveness analysis to clinical practice.

This article is intended to introduce the reader to the concepts of CEA/CBA for purposes of evaluating innovative pharmacy services. Furthermore, sensitization to the issues surrounding CEA/CBA studies should allow the reader to be more discriminating in reviewing such reports in the literature. Rising costs for health care and the existence of limited resources are forcing policy makers to allocate resources in ways that maximize return-on-investment. It is felt by some that in the 1980s, researchers will be expected to answer the questions, "How much better is the innovation?" and "How do the expected benefits of an innovation compare with the benefits that could be obtained if the resources were used in some alternative way?" Part of the solution will require changes in the training and practice of health professionals. Future physicians, pharmacists, and others will need to acquire skills from the behavioral, social, and decision sciences (e.g., epidemiology, statistics, economics, decision analysis). The notion of cost-effective clinical decision making needs to be taught at all levels. Health practitioners involved with decision making at the level of the patient need to become more knowledgeable of the overall impact (regarding costs and benefits) of their decisions. Finally, evaluation of innovative pharmacy services is but one element of a management program for clinical services. Our attempt is not to deemphasize the need for studies documenting the value of clinical services, but rather to put evaluation in perspective with an equally important need, the need for development of an overall pharmacy program that is not only cost effective but efficient as well. The means to this end is a total management program integrating all pharmacy services.

Cost-Benefit Analysis↗
PubMed2006

Fuzzy-logic optical optimization of mainframe CPU and memory.

The allocation of CPU time and memory resources is a familiar problem in organizations with a large number of users and a single mainframe. Usually the amount of resources allocated to a single user is based on the user's own statistics not on the statistics of the entire organization, therefore patterns are not well identified and the allocation system is prodigal. A fuzzy-logic-based algorithm to optimize the CPU and memory distribution among users based on their history is suggested. The algorithm works on heavy and light users separately since they present different patterns to be observed. The result is a set of rules generated by the fuzzy-logic inference engine that will allow the system to use its computing ability in an optimized manner. Test results on data taken from the Faculty of Engineering of Tel Aviv University demonstrate the capabilities of the new algorithm.

Journal Article↗
PubMed1992

Rationing and the long-term-care system.

Rationing is a concept newly introduced in health-systems analysis in the United States. Although rationing, when applied to health care, is a fearful word to the elderly, at the most basic level it is simply a method that enables government to intervene in the private marketplace to allocate resources to achieve particular policy ends. This intervention to affect allocation of health care resources has long been used by all levels of government in the United States. Intervention by government in the private marketplace is examined as a means of expanding or limiting the supply of health care services or expanding or limiting the demand for such services. The Oregon rationing experiment with Medicaid services has significantly contributed to the introduction of the concept of rationing of health care. As expected, there is a disproportionate interest by the elderly in rationing health care; thus the effect of the Oregon rationing experiment on the elderly is discussed, as are other allocation interventions on long-term care, as a service of particular interest to the elderly.

Aged↗
PubMed2003

Advanced access: reducing waiting and delays in primary care.

Delay of care is a persistent and undesirable feature of current health care systems. Although delay seems to be inevitable and linked to resource limitations, it often is neither. Rather, it is usually the result of unplanned, irrational scheduling and resource allocation. Application of queuing theory and principles of industrial engineering, adapted appropriately to clinical settings, can reduce delay substantially, even in small practices, without requiring additional resources. One model, sometimes referred to as advanced access, has increasingly been shown to reduce waiting times in primary care. The core principle of advanced access is that patients calling to schedule a physician visit are offered an appointment the same day. Advanced access is not sustainable if patient demand for appointments is permanently greater than physician capacity to offer appointments. Six elements of advanced access are important in its application balancing supply and demand, reducing backlog, reducing the variety of appointment types, developing contingency plans for unusual circumstances, working to adjust demand profiles, and increasing the availability of bottleneck resources. Although these principles are powerful, they are counter to deeply held beliefs and established practices in health care organizations. Adopting these principles requires strong leadership investment and support.

Appointments and Schedules↗
PubMed1997

Ethics of allocating intensive care unit resources.

ICU clinicians commonly make decisions that allocate resources. Because of the high cost of ICU care, these practitioners can expect to be involved in the growing dilemma of trying to meet increasing demand for healthcare services within financial constraints. In order to participate meaningfully in a societal discussion over fairness in allocating scare and expensive resources, ICU practitioners should have more than a superficial knowledge of the principles of distributive justice. Distributive justice refers to fairness in the distribution of limited resources and benefits. Fairness refers to giving equal treatment to all those who are the same with regard to certain morally significant characteristics and treating in a different manner those who are not the same. Although theoretical issues remain unresolved as to which characteristics should be most significant, the United States has a strong cultural value that regards individuals as inherently valuable and having equal social worth. From this, it is likely that only an egalitarian approach to allocation of lifesaving healthcare resources will be acceptable. Studies of how ICU resources have been allocated during times of scarcity indicates that, in general, when beds are scarce, the average severity of illness of those admitted to the ICU increases. However, in some hospitals, political and economic factors appear to play important roles in determining who has access to scarce ICU beds. Of great concern is documentation of a widespread pattern in which fewer hospital resources, including ICU resources, are provided to seriously ill patients of minority status or with low levels of insurance reimbursement. How society's values get translated into allocation decisions is another unresolved issue. One recent example of how this occurred is the Oregon Medicaid Plan. This plan extended Medicaid coverage to additional people in poverty, despite the same amount of state and federal funds. This was accomplished by not reimbursing what were regarded as marginally beneficial services on the basis of medical and community input. Portents of how society might be involved in the future of health care are illustrated by the argument that society should limit access to all therapies except palliative care solely on the basis of advanced age. Until an open consensus develops in U.S. society about how to allocate scarce healthcare resources, the delivery of ICU care will continue to be at risk of covert, de facto rationing based on ability to pay, race, or other nonmedical personal characteristics.

Cost Control↗
PubMedDate not supplied

[Allocation of medical resources to intensive care units].

Allocation of scarce and vital medical resources in intensive care units (ICUs) is one of the most actual and controversial questions within the context of medical ethics. How shall doctors decide which patients shall benefit from scarce resources such as ICU beds, ventilators, incubators, etc.? Which criteria are more acceptable from the ethical viewpoint in these triage situations: The rights of the patients? The expected benefits? The will of the patients or of their relatives? And how can medical responsibility be envisaged within this context? These are some of the questions discussed in this article having in mind the present framework of ethical and legal obligations pending upon doctors practicing in Portugal.

Critical Care↗
PubMed2002

Parental investment: how an equity motive can produce inequality.

The equity heuristic is a decision rule specifying that parents should attempt to subdivide resources more or less equally among their children. This investment rule coincides with the prescription from optimality models in economics and biology in cases in which expected future return for each offspring is equal. In this article, the authors present a counterintuitive implication of the equity heuristic: Whereas an equity motive produces a fair distribution at any given point in time, it yields a cumulative distribution of investments that is unequal. The authors test this analytical observation against evidence reported in studies exploring parental investment and show how the equity heuristic can provide an explanation of why the literature reports a diversity of birth order effects with respect to parental resource allocation.

Birth Order↗
PubMed2002

When branch autonomy fails: Milton's Law of resource availability and allocation.

The branch autonomy principle states that the critical characteristics of a branch's carbohydrate economy (photosynthesis, respiration, growth, etc.) are largely independent of the tree to which the branch is attached, as long as light is the primary factor limiting photosynthesis and growth. However, this may not be generally true because in the spring, photosynthates are translocated from a tree stem into branches, and the amount of photosynthate available for translocation should be a function of the tree's canopy status. And the correlative inhibition principle states that a branch's priority for allocation of carbon and other resources is controlled not only by its own environment, but also by its position relative to other branches on the same tree. A study of the lower limit of branch growth and survival in trees of different sizes shows that the latter principle is more important: even though dominant trees have more resources to allocate, branches on suppressed trees are able to grow and produce new foliage at solar irradiances where branches on dominant trees die. Thus branches are sufficiently interdependent that a positive carbon budget by itself does not ensure branch survival; branch position relative to other branches on the same tree is also important. Other findings indicate that this result is quite general: regardless of the stress involved, a stressed branch on a tree where all other branches are also stressed does better than a similarly stressed branch on a tree where some branches are relatively unstressed. Although branch autonomy is an important and useful principle, it is not an absolute rule governing branch growth.

Abies↗
PubMed1998

HIV-associated dementia: clinical, epidemiological and resource utilization issues.

Among mental disorders associated with HIV infection, dementia is the one most likely to have a major impact on public health, both as a result of the high levels of individual disability, and the greater demand of health care resource utilization. Epidemiologic and economic impact of HIV-associated dementia needs to be estimated, in order to provide policy makers and health managers with the information required for decision making and resource allocation. An increase in HIV encephalopathy prevalence rates may be expected as a consequence of longer survival time in dementia patients and in patients with other AIDS defining disease (longer survival increases the risk of developing HIV encephalopathy). A resource utilization study shows that, in the chronic stage of the disease, in-patient days per person-year are almost double in AIDS subjects with neurological complications as compared with those without neurological complications; no major difference appears when considering out-patients consultations and day-care treatments. In conclusion, a significant rise in resource utilization and in related costs may be anticipated as a consequence of the increasing prevalence of HIV encephalopathy. Further studies seem necessary to compare different approaches in the management of this debilitating disease, in view of a more rational utilization and allocation of resources.

AIDS Dementia Complex↗
PubMed1993

Rationing fairly: programmatic considerations.

CONCLUSION: I conclude with a plea against provincialism. The four problems I illustrated have their analogues in the rationing of goods other than health care. To flesh out a principle that says "people are equal before the law" will involve decisions about how to allocate legal services among all people who can make plausible claims to need them by citing that principle. Similarly, to give content to a principle that assures equal educational opportunity will involve decisions about resource allocation very much like those involved in rationing health care. Being provincial about health care rationing will prevent us from seeing the relationships among these rationing problems. Conversely, a rationing theory will have greater force if it derives from consideration of common types of problems that are independent of the kinds of goods whose distribution is in question. I am suggesting that exploring a theory of rationing in this way is a prolegomenon to serious work in "applied ethics."

Civil Rights↗
PubMed1995

Who cares about cost? Does economic analysis impose or reflect social values?

In a two-stage survey, a cross-section of Australians were questioned about the importance of costs in setting priorities in health care. Generally, respondents felt that it is unfair to discriminate against patients who happen to have a high cost illness and that costs should therefore not be a major factor in prioritising. The majority maintained this view even when confronted with its implications in terms of the total number of people who could be treated and their own chance of receiving treatment if they fall ill. Their position cannot be discarded as irrational, as it is consistent with a defensible view of utility. However, the results suggest that the concern with allocative efficiency, as usually envisaged by the economists, is not shared by the general public and that the cost-effectiveness approach to assigning priorities in health care may be imposing an excessively simple value system upon resource allocation decision-making.

Attitude to Health↗
PubMed2006

Prioritizing global conservation efforts.

One of the most pressing issues facing the global conservation community is how to distribute limited resources between regions identified as priorities for biodiversity conservation. Approaches such as biodiversity hotspots, endemic bird areas and ecoregions are used by international organizations to prioritize conservation efforts globally. Although identifying priority regions is an important first step in solving this problem, it does not indicate how limited resources should be allocated between regions. Here we formulate how to allocate optimally conservation resources between regions identified as priorities for conservation--the 'conservation resource allocation problem'. Stochastic dynamic programming is used to find the optimal schedule of resource allocation for small problems but is intractable for large problems owing to the "curse of dimensionality". We identify two easy-to-use and easy-to-interpret heuristics that closely approximate the optimal solution. We also show the importance of both correctly formulating the problem and using information on how investment returns change through time. Our conservation resource allocation approach can be applied at any spatial scale. We demonstrate the approach with an example of optimal resource allocation among five priority regions in Wallacea and Sundaland, the transition zone between Asia and Australasia.

Algorithms↗
PubMed2003

The surgeon and human immunodeficiency virus.

The moral dilemmas faced by surgeons worldwide who treat patients infected with the human immunodeficiency virus (HIV) can be viewed against the background of experience in sub-Saharan countries, where the community prevalence is in excess of 25% (90% of hospital inpatients). When seeking consent for an HIV test before surgery, frank communication regarding the surgeons' perspective of risks to themselves and the patient is helpful. When consent for a test must be obtained from a substitute decision-maker, the surgeon should consider if the patient would want the decision-maker to know the result. Understanding the natural history of HIV in the surgical setting can help deal with the uncertainties encountered and should be a research priority for developing countries. International professional organizations are useful platforms for the exchange of ideas when surgeons encounter uncertainty by increasing access to journals and creating opportunities for discussion. Although supervisory bodies in some parts of the world prevent HIV-infected surgeons from putting patients at risk by offering surgery, the withdrawal of their services in developing countries can cause more harm than good. Surgeons in that position may be entitled to offer surgery but only with full disclosure of the risk of HIV infection to the patient. The decision-making process known as "accountability for reasonableness" allows surgeons to determine fairness, legitimacy, and acceptability when making resource allocation decisions involving patients with HIV.

Decision Making↗
PubMed2000

School nursing: costs and potential benefits.

BACKGROUND: Previous reports that variations in school nursing resources across the UK had no relationship to deprivation; controversy about the changing role of the school nursing service. OBJECTIVES: To measure the resources allocated to school nursing, determine whether the variations can be explained by deprivation, and assess whether the allocation of school nursing time to a range of tasks is in line with current evidence and perceptions of changing needs. STUDY DESIGN: Quantitative economic analysis; qualitative descriptive study. SETTING: Detailed study of four English districts with diverse characteristics; staffing and service questionnaire and telephone survey of 62 districts. MAIN MEASURES: Staff resources and their salaries; measures of population and deprivation; activity statistics. RESULTS: There were wide variations in the cost of the school nursing service, but in contrast to previous reports 24% of the variance was explained by deprivation. There were no clear associations with any other social or educational variables. The greatest allocation of time was in routine screening and surveillance tasks. Relatively little time was allocated to other activities such as health promotion, support of special needs or unwell children, or teenage clinics. The expenditure on school nursing is only loosely related to deprivation and the results of this study offer guidance on what districts should spend to achieve equity of provision. CONCLUSIONS: The current allocation of resources to school nursing in between districts comparisons is not equitable and the use of school nursing time is out of step with current evidence of need and effectiveness.

Adolescent↗
PubMedDate not supplied

Acquiring new technology and surviving environmental pressures.

CONTEXT: The U.S. health care system faces increased pressures to expand coverage to the elderly, the uninsured and the poor, while maintaining costs and quality of care. Because of the federal budget deficit and continued fiscal uncertainties, resource allocation will become even more scrutinized. OBJECTIVE: How does a health care system allocate limited funds and still provide quality care using innovative technology? METHOD: This article reviews the literature on the acquisition of new technologies from a theoretical perspective, using positron emission tomography (PET) as an example. A unified model, including concepts from the resource dependency theory (RDT) supplemented with organizational survival concepts from the ecological theory, was used to analyze resource acquisition for technological innovation and organizational survival. An attempt was made to evaluate a hospital's profit maximization, recognition as a center of clinical excellence and role as a technological leader of the community with respect to acquisition of PET equipment. CONCLUSION: Organizations acquire new technology for a variety of reasons that can be explained by RDT and ecological theory concepts. In terms of the profit maximization motive, hospitals purchase PET equipment to enhance revenue generation. From the clinical excellence perspective, organizations seek the best available technology to meet the needs of their patients. Finally, hospitals adopt new technology to enhance their image as a technological leader.

Capital Expenditures↗
PubMed2005

Summary measures of caries prevalence to describe high-risk communities.

STUDY OBJECTIVE: This investigation compared the Significant Caries Index (SiC) with alternative summary measures of caries prevalence, designed to highlight high-risk communities and examined the implications of their use in health policy and planning in Wales. DESIGN: Data from the 2001 BASCD survey of 7,412, 12-year-old Welsh children were used in this analysis. As an alternative to the 33% cut-off value utilised in the SiC, the mean DMFT of children with the 10, 20 and 25% highest caries scores were calculated for 22 local health board areas, as was the mean DMFT for the whole population, %DMFT >0, and the mean for those with DMFT >0, >1, >2, and >3. SETTING: Examinations for the childhood epidemiology programme took place in Welsh secondary schools. PARTICIPANTS: 12-year-old children examined in the 2000/01 survey. MAIN RESULTS: The mean DMFT for the whole population was 1.31, and the mean DMFT of those with caries was 2.56. The mean DMFT for SiC 33%, 25%, 20% and 10% was: 3.39, 3.85, 4.28, and 5.31 respectively. When local health board areas were ranked according to mean DMFT score at different percentage cut-off points, variation in rank order was observed, the greatest difference in rank order being 6. Furthermore, when compared with summaries based on DMFT scores traditionally used in Wales, even greater rank differences were noted (up to 14 places). CONCLUSIONS: Rank order of geographical area is influenced by the definition of the index chosen when describing high risk populations using a variety of caries indices. This has implications for health policy planning and resource allocation.

Catchment Area, Health↗
PubMed1993

QALYs (Quality Adjusted Life Years): a nurse's view.

Examines the political and ideological significance of measures of quality of life, specifically Quality Adjusted Life Years (QALYs). Briefly reviews recent developments in the debate surrounding the economic and political functions of quality of life measures. The dialectic between conceptions of the quality of life and the implicit realpolitik of socio-economic pressures, ecological conditions, political ethos and cultural norms and expectations, is conceived as a powerful means for the critique of our aspirations concerning health. Argues that existing approaches to assessing quality of life, in denying this dialectic, have jeopardized their potential contribution to the planning, implementation and evaluation of health are policy. Resource allocation challenges us to develop openly ideological strategies and measures.

Australia↗